Understanding the Effects of Medicaid Innovation

Considerations for Evaluating State Medicaid Policies


Executive Summary

Section 1115 Medicaid demonstrations are important vehicles for experimenting with new Medicaid policies. Rigorous evaluations of these policies, if done well, can inform Governors and other state leaders, federal partners and additional stakeholders in how to shape the future of the program. Until recently, many Section 1115 Medicaid demonstration evaluations lacked precision. This is changing – as the federal focus shifts to learning from state demonstrations, evaluation plans are more thorough and rigorous.

Recognizing this evolving landscape and the importance of rigorous state evaluations, in 2018, the National Governors Association Center for Best Practices (NGA Center) launched a project titled, “Building State Capacity to Evaluate Innovative Medicaid Policies.” The project’s goal was to support Governors and state leaders in evaluating new Medicaid policies implemented under Section 1115 waiver authority. With funding from the Robert Wood Johnson Foundation, the NGA Center, in partnership with the University of Minnesota State Health Access Data Assistance Center, engaged in a project to support evaluation efforts in Alaska, Colorado, Illinois and New Hampshire. Drawing on that work, this brief summarizes key considerations and outlines promising tactics for states to use in evaluating new Medicaid policies.

Since the launch of this project, Governors and their staff have been responding to the unprecedented public health crisis caused by the COVID-19 pandemic. The resulting jump in unemployment, projected shortfalls in state revenue and increased rates of the uninsured will affect Medicaid programs across the country. As state leaders seek solutions to manage their Medicaid programs in the face of increased enrollment and smaller budgets, new ideas will likely emerge for how to operate the program (through Section 1115 waiver authority or otherwise). As part of that innovation, state leaders should evaluate the impact of these changes on Medicaid enrollees, cost and sustainability.

Considerations and Strategies for Governors and Their Staff in Evaluating State Medicaid Policies

Prioritizing goals for evaluation:

  • Start evaluation discussions early with the Centers for Medicare & Medicaid Services (CMS).
  • Consider how implementation choices affect evaluation planning and budgeting.
  • Keep sight of state goals.

Developing a timeline to support evaluation:

  • Focus on CMS evaluation milestones.
  • Anticipate the interplay between implementation and evaluation timelines.
  • Consider which state activities to include in the evaluation timeline.

Designing an evaluation plan that reflects goals and resources:

  • Assess state evaluation resources.
  • Invest in evaluation activities that address key goals.
  • Draw heavily from CMS guidance when drafting the evaluation design.
  • When evaluation questions are firm, identify relevant data sources.

Building an effective relationship with an evaluation partner:

  • Discuss in advance the scope and role of the independent evaluator.
  • Balance the ideal contractor-selection process with real timeline and budget constraints.

Section 1115 demonstrations and evaluations of their effectiveness are a prime example of how states serve as the laboratories of innovation. Continued cross-state learning facilitated by the NGA Center, CMS and other stakeholders is key to improving evaluation rigor and understanding the effects of Medicaid policy innovations.